ACEN Accreditation Manual – Policy 24

ACCREDITATION MANUAL  •  SECTION I GENERAL INFORMATION  •  SECTION II POLICIES  •  SECTION III STANDARDS AND CRITERIA  •  GLOSSARY

ACEN Accreditation Manual – Section II Policies

POLICY #24
Assessment of the Adequacy of Standards and Criteria, ACEN Process, and Practices

The ACEN maintains an ongoing, systematic review designed to ensure that (1) the Standards and Criteria are valid and reliable indicators of the educational quality provided by accredited programs and are relevant to the educational needs of students; (2) ACEN processes are reliable and assess knowledge and consistency of observations, applications, decisions, and perceptions, and (3) there are broad communications and consultations across constituencies.

The findings from the ongoing review are used for development, maintenance, and revision of the Standards and Criteria, processes, and practices. Evidence to support ongoing systematic review appears in commission meeting minutes, annual reports, the ACEN Report to Constituents, on the ACEN website, and at ACEN events. 

The Process of Review of the Standards and Criteria

The process of review:

  1. Is comprehensive.
  2. Occurs at regular intervals, which is every five years unless it is determined at any point during the systematic review/analysis of data that changes are needed to the Standards and Criteria. If the review/analysis shows that changes are needed, the ACEN will initiate a review of the Standards and Criteria within 12 months of this determination, and the ACEN will complete the review within a reasonable period of time.
  3. Examines each Standard and its accompanying Criteria as a whole.
  4. Involves relevant constituencies such as nursing students, representatives from nursing education (nurse educator/clinician), nursing service (nurse clinician/practitioner), and other constituents in the review.
  5. Affords relevant constituencies a meaningful opportunity to provide input into the review.
  6. Requires that needed changes be made promptly to improve the ACEN’s effectiveness and efficiency as well as the consumer friendliness of ACEN products and services.

Aspects of the Review of the Standards and Criteria

A comprehensive review of the Standards and Criteria consists of:

  1. Review of ACEN program data and trends.
  2. Review of literature for trends in nursing practice and nursing education.
  3. Review of U.S. Department of Education Regulations.
  4. Review of Council for Higher Education Accreditation Recognition Policy and Procedures.
  5. Notice to constituencies of proposed changes to the Standards and Criteria with the opportunity for constituencies to make comment on the proposed changes. There will be two public comment periods; each public comment period will be at least 30 calendar days.
  6. Review of comments from the public comment periods and revision of proposed changes to the Standards and Criteria as applicable.
  7. Board of Commissioners adoption of revised Standards and Criteria.

Reliability of ACEN Processes

Reliability is ensured by:

  1. Analysis of internal consistency of the accreditation status recommendations/decisions across the three levels of review by and among all program types per accreditation review cycle and trended over time.
  2. Identification of non-compliance and areas needing development by criterion among all program types per accreditation review cycle and trended over time.
  3. Analysis of the perceived effectiveness of the planning and conduct of the accreditation site visit by the nursing program and the site visit teams by program type per accreditation review cycle and trended over time. 

Communication and Broad Consultation Practices

Communication is ensured by:

  1. Solicitation of comments on proposed new or revised policies from interested parties.
  2. Distribution of the Annual Report findings in the Report to Constituents and on the ACEN website as aggregated data trended over time.
  3. Broad consultation across constituencies. 

Planned Use of Data Analysis

Data analysis is used to:

  1. Maintain validity and relevance of the Standards and Criteria.
  2. Maintain reliability of the ACEN accreditation processes and practices.
  3. Continue to identify and disseminate information in appropriate arenas regarding specific education needs of nursing programs and peer evaluators as groups.
  4. Continue to identify and disseminate information in appropriate arenas regarding specific developmental needs of nursing programs and peer evaluators.
  5. Continue to identify and disseminate information through appropriate means regarding areas in which change(s) needs to be facilitated. 

Evaluation of the Site Visit

For each site visit, the nurse administrator of the nursing program, team chair, and team members have an evaluation form to complete. The information is used to:

  1. Improve the quality of the accreditation process.
  2. Identify potential team chairs.

Annual Report

All accredited nursing programs are required to submit an Annual Report. The Annual Report will request at minimum the following program outcome information:

  1. Program completion rates.
  2. Job placement rates.
  3. Licensure and/or certification examination pass rates.

The ACEN staff will review the information to ensure that nursing programs continue to comply with policies and reporting requirements. Significant changes will be referred to the ACEN Board of Commissioners, and action may be taken as appropriate. Failure to submit the Annual Report could result in the ACEN Board of Commissioners taking appropriate action, including potentially altering the program’s accreditation status.

Data about individual programs will be used for monitoring purposes. Data about all programs will be reported publicly in aggregate form only and trended over time.

Programs with Title IV-HEA responsibilities must also submit information regarding compliance with their Title IV responsibilities and the result of financial or compliance audits in accordance with Policy #22 Program Accreditation Status in Relation to State and Other Accrediting Agency Actions.

Policy #24 History
Revised November 2015
Edited October 2016
Revised November 2018
Revised March 2019
Revised July 2022
Edited June 2023

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